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NORTHWEST WISCONSIN COMMUNITY SERVICES AGENCY, INC. VOLUNTEER APPLICATION

FIRST & LAST NAME:
MAILING ADDRESS:
EMAIL ADDRESS:
HOME PHONE:
CELL PHONE:
BEST TIME TO CALL: AM  PM
DO YOU SPEAK A FOREIGN LANGUAGE? YES  NO
IF YES, WHICH LANGUAGE?
DO YOU DRIVE: YES  NO
DO YOU HAVE REGULAR ACCESS TO A CAR? YES  NO
CURRENT COMMUNITY ACTIVITIES:  
LIST CURRENT AND PREVIOUS VOLUNTEER WORK (LIST ALL PREVIOUS VOLUNTEER WORK INCLUDING BRIEF DESCRIPTION OF DUTIES AND ACTIVITIES, DATES OF SERVICE):
WHAT ARE YOUR REASONS FOR WANTING TO PARTICIPATE AS A NWCSA VOLUNTEER?
WHICH VOLUNTEER POSITION ARE YOU APPLYING FOR?  FREE STORE  FOOD SHELF  SOLID ROCK SAFE HAVEN 
TAX ASSISTANCE PROGRAM 
MEMORY LANE  LEW MARTIN SENIOR CENTER
HOW DID YOU LEARN ABOUT NWCSA:  
HAVE YOU EVER BEEN CONVICTED OF A CRIME OTHER THAN A TRAFFIC VIOLATION?  YES  NO
IF YES, WHAT CHARGE?  DATE CONVICTED:  
IF YES, WHERE WERE YOU CONVICTED?
DO YOU CONSENT TO A ROUTINE CHECK OF YOUR CRIMMINAL RECORDS?  YES  NO
CAN YOU THINK OF ANY REASON WHY NWCSA MIGHT BE RELUCTANT FOR YOU TO SERVE AS A VOLUNTEER?
EDUCATION: HIGH SCHOOL: 10  11  12
COLLEGE: 4
GRADUATE: 4
MAJOR:
DEGREE:
NAME OF SCHOOL:

WORK/ VOLUNTEER HISTORY

NAME AND ADDRESS OF PRESENT OR LAST
EMPLOYER OR VOLUNTEER PROJECT:
DATES:   SUPERVISOR'S NAME:
BRIEF DESCRIPTION OF WORK:

WORK/ VOLUNTEER HISTORY

NAME AND ADDRESS OF PRESENT OR LAST
EMPLOYER OR VOLUNTEER PROJECT:
DATES:   SUPERVISOR'S NAME:
BRIEF DESCRIPTION OF WORK:

WORK/ VOLUNTEER HISTORY

NAME AND ADDRESS OF PRESENT OR LAST
EMPLOYER OR VOLUNTEER PROJECT:
DATES:   SUPERVISOR'S NAME:
BRIEF DESCRIPTION OF WORK:

REFERENCES

PLEASE LIST THREE REFERENCES OF PEOPLE WHO KNOW YOU WELL, OTHER THAN RELATIVES, PREFERABLY FOR WHOM YOU HAVE WORKED IN EITHER A PAID OR VOLUNTEER CAPACITY. IF YOU ARE CURRENTLY WORKING, EITHER PAID OR AS A VOLUNTEER, PLEASE INCLUDE THE NAME OF YOUR SUPERVISOR.
NAME:  
ADDRESS:
ZIP CODE:
PHONE:
RELATIONSHIP:
   
NAME:  
ADDRESS:
ZIP CODE:
PHONE:
RELATIONSHIP:
   
NAME:  
ADDRESS:
ZIP CODE:
PHONE:
RELATIONSHIP:
   
HOW LONG HAVE YOU LIVED IN THE AREA?

AVAILABILITY


AS A NWCSA VOLUNTEER WILL YOU BE REQUIRED TO ATTEND ORIENTATION AND CIVIL RIGHTS TRAINING. WILL YOU BE ABLE TO ARRANGE YOUR SCHEDULE TO
ATTEND THESE TRAININGS?

YES  NO
ARE YOU WILLING TO COMMIT TO TWO SEASONS OF VOLUNTEER SERVICES? (CHECKING NO DOES NOT PREVENT YOU FROM BECOMING A VOLUNTEER).

 YES  NO

NORTHWEST WISCONSIN COMMUNITY SERVICES AGENCY, INC. RESERVES THE RIGHT TO MAKE ANY CHECKS DEEMED APPROPRIATE AS TO THE SUITABILITY OF ANYONE RESPONSIBLE FOR THIS CONFIDENTIAL WORK. ALL INFORMATION OBTAINED WILL BE HELD IN THE STRICTEST CONFIDENCE.

APPLICANT SIGNATURE:   DATE (DD/MM/YY)